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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110017
Report Date: 10/11/2023
Date Signed: 01/08/2024 12:42:48 PM

Document Has Been Signed on 01/08/2024 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FAIRFAX SAN ANSELMO CHILDREN'S CENTER-SCHOOL AGEFACILITY NUMBER:
210110017
ADMINISTRATOR:TOMSKY, HEIDIFACILITY TYPE:
840
ADDRESS:199 PORTEOUS AVENUETELEPHONE:
(415) 454-1811
CITY:FAIRFAXSTATE: CAZIP CODE:
94930
CAPACITY: 65TOTAL ENROLLED CHILDREN: 65CENSUS: 0DATE:
10/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Heidi TomskyTIME COMPLETED:
12:40 PM
NARRATIVE
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***** THIS IS AN AMENDED REPORT FROM ORIGINAL DATED 10/11/23 *****

On October 11, 2023, Licensing Program Analyst (LPA) Garcia and Licensing Program Manager (LPM) Oquendo conducted unannounced case management deficiencies visit and met with director, Heidi Tomsky and program director, Eric Schweninger. The purpose of the inspection was explained. There were no children present in the program during the time of visit.

During the visit, LPA and LPM observed and inspected the three licenses housed under the same property, preschool license number 210110015, school age license number 210110017 and the infant license number 210110016.

LPA and LPM inspected and observed day care rooms and the outdoor space for any health and safety hazards. The potential and health and safety risk that were observed that the facility has missing ceiling panels, signs of water damage, broken windows and exposed wires.

Therefore, the facility will be cited under CCR 101238.


Report, Appeal Rights and Notice of Site Visit was provided.

Notice of Site Visit shall be posted for 30 consecutive days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Director, Heidi Tomsky.
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SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2023 12:29 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/11/2023 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FAIRFAX SAN ANSELMO CHILDREN'S CENTER-SCHOOL AGE
FACILITY NUMBER: 210110017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/13/2023
Section Cited
CCR
101169(d)(3)

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101169 Application for License
(d) The LIC 281A (12/96) and supporting documents shall together contain the following:
(3) If the applicant is leasing or renting the premises of the child care center, a copy of the lease or rental agreement and the name, address and telephone number of the property owner.

This requirement has not been met as evidenced by:
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The facility will provide a signed written agreement from the landlord.
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Based on observations conducted and pertinent documents received, the facility does not have a current lease agreement with the landlord.

This pose a potential health and safety risk to children in care.
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This facility will send proof by set due date.
Type B
11/13/2023
Section Cited
CCR101238

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101238 Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement has not been met as evidenced by:
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The facility will make the necessary repairs to the property and send proof to the LPA. The facility will also contact the Fire department to inspect the facility.
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Based on observations conducted and pertinent documents received, the facility has missing ceiling panels, signs of water damage, broken windows and exposed wires.

This pose a potential health and safety risk to children in care.
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The proof of necessary repairs will be sent by set due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
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